The determinants of expert opinion in the development of care pathways: insights from an exploratory cluster analysis

Background We performed a secondary exploratory cluster analysis on the data collected from the validation phase of the study leading to the development of the model care pathway (CP) for Myasthenia Gravis (MG), in which a panel of 85 international experts were asked some characteristics about themselves and their opinion about the model CP. Our aim was to identify which characteristics of the experts play a role in the genesis of their opinion. Methods We extracted the questions probing an opinion and those describing a characteristic of the expert from the original questionnaire. We performed a multiple correspondence analysis (MCA) and a subsequent hierarchical clustering on principal component (HCPC) on the opinion variables, integrating the characteristic variables as supplementary (predicted). Results After reducing the dimensionality of the questionnaire to three dimensions we noticed that the not-appropriateness judgement of the clinical activities may overlap with the completeness one. From the HCPC it seems that the working setting of the expert may play a crucial role in determining the opinion about the setting of the sub-processes of MG: shifting from a cluster where the experts do not work in sub-specialist settings to one where the experts are working in them, the opinion changes accordingly from a mono-disciplinary setting to a multi-disciplinary one. Another interesting result is that the experience in neuromuscular diseases (NMD) measured in years and the expert typology (whether general neurologist or NMD expert) seem not to contribute significantly to the opinions. Conclusions These findings might indicate a poor ability of the expert to discriminate what is not appropriate from what is not complete. Also, the opinion of the expert might be influenced by the working setting, but not by the experience in NMD (as measured in years). Supplementary Information The online version contains supplementary material available at 10.1186/s12913-023-09139-7.


15(b). Could you please indicate the single most important typology/category of patients that should be excluded from this
part of the process of MG care and the determining reason. Please also include the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients cannot be included in the pathway.: Reasons 15(c). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please also include the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients cannot be included in the pathway.: Level of evidence 4.Please select which type of institution are you working? Note: you can select more than one option. 5.Please select the setting where you are working Note: you can select more than one option. 9.Could you please flag the not appropriate ones from the following list.
10.Please analyze the below list of activities/interventions included in the subprocess (Diagnosis and assessment ) that you examined before. Could you please rank the importance of those activities from 1 to 10 where 1 is the most important? (we realize that some activities will get similar importance but to prioritize them, you cannot attribute the same ranking for several activities). Note: To rank the activities you can either attribute the number directly in the box or drag them in the order you wish. Myasthenia Gravis Pathway -Complete Questionnaire 15(d). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please also include the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients cannot be included in the pathway.: Reference/Citation Ambulatory care Hospital day care Hospital in-patient Long-term care (nursing home) Long-term care (rehabilitation) Other

Q17
17.How is this list of activities/interventions is differing from the guidelines that you are using in your daily practice?

Q18
18.Based on your experience did you find any, not appropriate activity/intervention that was included in the above process flow?

Yes / No
Patient with mild signs and symptoms: Start with acetylcholinesterase inhibitors.
Check whether the patient has Changed in Bowel Pattern -Diarrhea during Acetylcholinesterase inhibitor treatment, if yes then 1.) Maintain a record of intake and output and number of stools. 2.) Monitor electrolyte studies Increase fluid intake. (Note: Carefully monitor Na and water retention in patients taking corticosteroids). 4.) Advance diet from liquid to bland to regular diet as tolerated. 5.) Instruct the patient to avoid foods such as fresh fruit, salads, or spicy or fried foods that may aggravate diarrhoea. 6.) Assess muscle strength to determine changes related to overdosage/under dosage of cholinesterase inhibitor medications. 7.) Instruct the patient to consult a physician for medications to control diarrhoea.
If the patient does not respond with acetylcholinesterase inhibitors and the patient has Generalised MG (anti-AChR positive) consider thymectomy (if early onset of thymoma) and prescribe prednisone or prednisone plus azathioprine or mycophenolate mofetil. If the patient does not respond with acetylcholinesterase inhibitors and has Generalised MG (anti-MuSK positive) then prescribe prednisone or prednisone plus azathioprine or mycophenolate mofetil. If the treatment response is not good with prednisone or prednisone plus azathioprine or mycophenolate mofetil then switch to cyclosporin or tacrolimus or methotrexate, IVIg or subcutaneous immunoglobulin -Avoid salted snacks. 4.) Read food labels for sodium content. 5.) Avoid canned foods or frozen foods that add salt to food preparation. 6. ) Monitor lab values and vital signs, and characteristics of pulse. 7.) Assess changes in muscle strength. 8.) Assist patient to include foods high in potassium, such as citrus fruits, green vegetables, meats, whole grain foods and fish. 9.) Instruct patient on principles of good nutrition. 10.) Instruct patients to avoid fad diets and to consult a physician before starting a weight loss program. 11.)Advise patient that fluctuations in appetite are a normal effect of steroid medications that require a conscious effort to control. 12.) Provide emotional support when changes in body image occur from weight gain from steroids. Patient with severe or moderate oropharyngeal signs/symptoms of MG, or respiratory crisis: Provide Supportive care, Bilevel positive-pressure ventilation, intubate if necessary, stop cholinesterase inhibitors and treat with PE or IVIg Patient with mild signs and symptoms: Start with acetylcholinesterase inhibitors.
Check whether the patient has Changed in Bowel Pattern -Diarrhea during Acetylcholinesterase inhibitor treatment, if yes then 1.) Maintain a record of intake and output and number of stools. 2.) Monitor electrolyte studies Increase fluid intake. (Note: Carefully monitor Na and water retention in patients taking corticosteroids). 4.) Advance diet from liquid to bland to regular diet as tolerated. 5.) Instruct the patient to avoid foods such as fresh fruit, salads, or spicy or fried foods that may aggravate diarrhoea. 6.) Assess muscle strength to determine changes related to overdosage/under dosage of cholinesterase inhibitor medications. 7.) Instruct the patient to consult a physician for medications to control diarrhoea.
If the patient does not respond with acetylcholinesterase inhibitors and the patient has Generalised MG (anti-AChR positive) consider thymectomy (if early onset of thymoma) and prescribe prednisone or prednisone plus azathioprine or mycophenolate mofetil. If the patient does not respond with acetylcholinesterase inhibitors and has Generalised MG (anti-MuSK positive) then prescribe prednisone or prednisone plus azathioprine or mycophenolate mofetil. If the treatment response is not good with prednisone or prednisone plus azathioprine or mycophenolate mofetil then switch to cyclosporin or tacrolimus or methotrexate, IVIg or subcutaneous immunoglobulin If the treatment response is not good with cyclosporin or tacrolimus or methotrexate, IVIg or subcutaneous immunoglobulin then switch to cyclophosphamide, rituximab or eculizumab, serial PE or IVIg If the patient does not respond to cyclophosphamide, rituximab or eculizumab, serial PE or IVIg. Then perform the reevaluation of diagnosis After the re-evaluation of diagnosis, if the patient evaluated positive to anti-AChR or anti-MuSK then treat by reinstituting last effective dose, high or moderate dose prednisone, PE or IVIg if severe, Add or change immunosuppression. If the treatment response is not good with acetylcholinesterase inhibitors and the patient has only ocular MG then prescribe prednisone. If there is disappearance of the ocular signs and symptoms then continue treatment with lowest dose The patients who take prednisone need to be evaluated: a.) The Alteration in Fluid Balance Related to Na and H2O Retention. b.) Electrolyte Imbalance Related to Potassium Loss. c.) Weight Gain Related to Increased Appetite and Water Retention Patient who take prednisone and evaluated positive to; a.) Alteration in Fluid Balance Related to Na and H2O Retention. b.) Electrolyte Imbalance Related to Potassium Loss. c.) Weight Gain Related to Increased Appetite and Water Retention, then assist the patient with below interventions.
1.) Maintain a record of intake and output. 2.) Daily weights. 3.) Instruct patient on ways to decrease salt intake: -No added salt to food preparation. -No added salt to food at meal time. -Avoid salted snacks. 4.) Read food labels for sodium content. 5.) Avoid canned foods or frozen foods that add salt to food preparation. 6. ) Monitor lab values and vital signs, and characteristics of pulse. 7.) Assess changes in muscle strength. 8.) Assist patient to include foods high in potassium, such as citrus fruits, green vegetables, meats, whole grain foods and fish. 9.) Instruct patient on principles of good nutrition. 10.) Instruct patients to avoid fad diets and to consult a physician before starting a weight loss program. 11.)Advise patient that fluctuations in appetite are a normal effect of steroid medications that require a conscious effort to control. 12.) Provide emotional support when changes in body image occur from weight gain from steroids. Patient with severe or moderate oropharyngeal signs/symptoms of MG, or respiratory crisis: Provide Supportive care, Bilevel positive-pressure ventilation, intubate if necessary, stop cholinesterase inhibitors and treat with PE or IVIg Q21 21.Based on your experience, do you consider the above process flow complete? Yes / No 22(a). Could you please specify in the below box which activity/intervention is missing (level of evidence and the eventual reference).: clinical activity/Intervention 22(b). Could you please specify in the below box which activity/intervention is missing (level of evidence and the eventual reference).: Level of Evidence 22(c). Could you please specify in the below box which activity/intervention is missing (level of evidence and the eventual reference).: Reference/Citation Q23 23.Based on your practical experience, could you please highlight the single most important potential bottleneck to the above process you may foresee as well at their frequency of occurrence? Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. The organisational prerequisite when implementing this recommendation in real practice is the availability of operating room 24hrs seven days a week. In this case, several bottlenecks can affect this process: for example during the summertime, it is likely that one hospital could reduce its activities because of the lack of personal for vacation. As a possible consequence, the trauma operating room will be open only five days a week from 8:00-20:00. In such a scenario if a patient is admitted for a hip fracture on Friday afternoon it will be impossible to be compliant with the recommendation. This is how an organisational bottleneck could affect the clinical process. 24(a). What is the single most relevant outcome that can be influenced/determined by this part of the process of care? Please, indicate for each outcome its level of evidence (scientific literature and/or clinical expertise and/or your opinion).Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increased risk of negative outcomes (patients death and pressure sores). : Outcomes 24(b). What is the single most relevant outcome that can be influenced/determined by this part of the process of care? Please, indicate for each outcome its level of evidence (scientific literature and/or clinical expertise and/or your opinion).Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increased risk of negative outcomes (patients death and pressure sores). : Level of evidence 16.According to your opinion, what is the most frequent setting where the above process is currently executed? (more than one answer allowed) 19.Could you please flag the not appropriate ones from the following list. 20.Please have a look at the below list of activities/interventions included in the subprocess (MG assessment and pharmacological management) that you examined before. Could you please provide us with your opinion ranking the importance of those activities from 1 to 12 where 1 is the most important? (we realize that some activities will get similar importance but to prioritize them, you cannot attribute the same ranking for several activities). Note: To rank the activities you can either attribute the number directly in the box or drag them in the order you wish. Q15 Q16 Q19 Q20 Q22 Q24 24(c). What is the single most relevant outcome that can be influenced/determined by this part of the process of care? Please, indicate for each outcome its level of evidence (scientific literature and/or clinical expertise and/or your opinion).Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increased risk of negative outcomes (patients death and pressure sores). : Reference/Citation 25(a). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Typology/category of patients should be excluded

25(b). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission.
If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Reasons 25(c). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Level of evidence 25(d). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Reference/Citation Ambulatory care Hospital day care Hospital in-patient Long-term care (nursing home) Long-term care (rehabilitation) Other

Q27
27.How is this list of activities/interventions is differing from the guidelines that you are using in your daily practice?

Q28
28.Based on your experience did you find any, not appropriate activity/intervention that was included in the above process flow? 31.Based on your experience, do you consider the above process flow complete? Yes / No 32(a). Could you please specify in the below box which activity/intervention is missing (level of evidence and the eventual reference).: clinical activity/Intervention 32(b). Could you please specify in the below box which activity/intervention is missing (level of evidence and the eventual reference).: Level of Evidence 32(c). Could you please specify in the below box which activity/intervention is missing (level of evidence and the eventual reference).: Reference/Citation Q33 33.Based on your practical experience, could you please highlight the single most important potential bottleneck to the above process you may foresee as well at their frequency of occurrence? Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. The organisational prerequisite when implementing this recommendation in real practice is the availability of operating room 24hrs seven days a week. In this case, several bottlenecks can affect this process: for example during the summertime, it is likely that one hospital could reduce its activities because of the lack of personal for vacation. As a possible consequence, the trauma operating room will be open only five days a week from 8:00-20:00. In such a scenario if a patient is admitted for a hip fracture on Friday afternoon it will be impossible to be compliant with the recommendation. This is how an organisational bottleneck could affect the clinical process.

34(a). What is the single most relevant outcome that can be influenced/determined by this part of the process of care?
Please, indicate for each outcome its level of evidence (scientific literature and/or clinical expertise and/or your opinion).Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increased risk of negative outcomes (patients death and pressure sores). : Outcomes 34(b). What is the single most relevant outcome that can be influenced/determined by this part of the process of care? Please, indicate for each outcome its level of evidence (scientific literature and/or clinical expertise and/or your opinion).Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increased risk of negative outcomes (patients death and pressure sores). : Level of evidence 34(c). What is the single most relevant outcome that can be influenced/determined by this part of the process of care? Please, indicate for each outcome its level of evidence (scientific literature and/or clinical expertise and/or your opinion).Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increased risk of negative outcomes (patients death and pressure sores). : Reference/Citation 35(a). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Typology/category of patients should be excluded 35(b). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Reasons 26.According to your opinion, what is the most frequent setting where the above process is currently executed? (more than one answer allowed) 29.Could you please flag the not appropriate ones from the following list.
30.Please have a look at the below list of activities/interventions included in the subprocess (assessment and pharmacological management of MG crisis) that you examined before. Could you please provide us with your opinion ranking the importance of those activities from 1 to 5 where 1 is the most important? (we realize that some activities will get similar importance but to prioritize them, you cannot attribute the same ranking for several activities). Note: To rank the activities you can either attribute the number directly in the box or drag them in the order you wish.

Q26
Q29 Q30 Q32 Q34 Q35 35(c). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Level of evidence

35(d). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Reference/Citation
Ambulatory care Hospital day care Hospital in-patient Long-term care (nursing home) Long-term care (rehabilitation) Other

Q37
37.How is this list of activities/interventions is differing from the guidelines that you are using in your daily practice? Q38 38.Based on your experience did you find any, not appropriate activity/intervention that was included in the above process flow? Compensatory Maneuvers: chin tuck, head turn or supraglottic swallow for eliminating or decreasing aspiration.

41.Based on your experience, do you consider the above process flow complete? Yes / No 42(a). Could you please specify in the below box which activity/intervention is missing (level of evidence and the eventual reference).: clinical activity/Intervention 42(b). Could you please specify in the below box which activity/intervention is missing (level of evidence and the eventual reference).: Level of Evidence 42(c). Could you please specify in the below box which activity/intervention is missing (level of evidence and the eventual reference).: Reference/Citation
Q43 43.Based on your practical experience, could you please highlight the single most important potential bottleneck to the above process you may foresee as well at their frequency of occurrence? Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. The organisational prerequisite when implementing this recommendation in real practice is the availability of operating room 24hrs seven days a week. In this case, several bottlenecks can affect this process: for example during the summertime, it is likely that one hospital could reduce its activities because of the lack of personal for vacation. As a possible consequence, the trauma operating room will be open only five days a week from 8:00-20:00. In such a scenario if a patient is admitted for a hip fracture on Friday afternoon it will be impossible to be compliant with the recommendation. This is how an organisational bottleneck could affect the clinical process.

44(a). What is the single most relevant outcome that can be influenced/determined by this part of the process of care?
Please, indicate for each outcome its level of evidence (scientific literature and/or clinical expertise and/or your opinion).Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increased risk of negative outcomes (patients death and pressure sores). : Outcomes 44(b). What is the single most relevant outcome that can be influenced/determined by this part of the process of care? Please, indicate for each outcome its level of evidence (scientific literature and/or clinical expertise and/or your opinion).Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increased risk of negative outcomes (patients death and pressure sores). : Level of evidence 44(c). What is the single most relevant outcome that can be influenced/determined by this part of the process of care? Please, indicate for each outcome its level of evidence (scientific literature and/or clinical expertise and/or your opinion).Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increased risk of negative outcomes (patients death and pressure sores). : Reference/Citation 45(a). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Typology/category of patients should be excluded 36.According to your opinion, what is the most frequent setting where the above process is currently executed? (more than one answer allowed) 39.Could you please flag the not appropriate ones from the following list.
40.Please have a look at the below list of activities/interventions included in the subprocess (Speech, swallowing and dental functioning) that you examined before. Could you please provide us with your opinion ranking the importance of those activities from 1 to 6 where 1 is the most important? (we realize that some activities will get similar importance but to prioritize them, you cannot attribute the same ranking for several activities). Note: To rank the activities you can either attribute the number directly in the box or drag them in the order you wish. Q35 Q36 Q39 Q40 Q42 Q44 45(b). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Reasons 45(c). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Level of evidence 45(d). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Reference/Citation Ambulatory care Hospital day care Hospital in-patient Long-term care (nursing home) Long-term care (rehabilitation) Other Home Management: 1.) Perform laundry in smaller loads. 2.) Use laundry hampers on casters that allow for ease in rolling rather than lifting. 3.) Organize frequently used cooking equipment/ utensils to allow ease in reaching and reduced trips to collect. 4.) Use lightweight equipment rather than heavy vacuum cleaners or mops.
Shopping: 1.) Plan shopping trips during the time of day that one has the most energy. 2.) Consider grocery stores that provide a "call-in" and pick-up service. Parenting: Arrange diaper changing stations to allow performance while seated. Care of Pets: 1.) Use elevated food container on casters. 2.) Use elevated feeding stations. 3.) Hire someone to take pets for a walk. Leisure Activities: 1.) Perform more strenuous activities during peak medication response. 2.) Learn early signs of fatigue and allow sufficient recovery time. 3.) Balance strenuous activities with ones that require less physical exertion. Sexual Activity: 1.) Plan sexual activities at times when concern for fatigue is not a factor. 2.) Utilize positions that require less energy for posture. Q51 51.Based on your experience, do you consider the above process flow complete? Yes / No 52(a). Could you please specify in the below box which activity/intervention is missing (level of evidence and the eventual reference).: Clinical activity/Intervention 52(b). Could you please specify in the below box which activity/intervention is missing (level of evidence and the eventual reference).: Level of evidence 52(c). Could you please specify in the below box which activity/intervention is missing (level of evidence and the eventual reference).: Reference Q53 53.Based on your practical experience, could you please highlight the single most important potential bottleneck to the above process you may foresee as well at their frequency of occurrence? Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. The organisational prerequisite when implementing this recommendation in real practice is the availability of operating room 24hrs seven days a week. In this case, several bottlenecks can affect this process: for example during the summertime, it is likely that one hospital could reduce its activities because of the lack of personal for vacation. As a possible consequence, the trauma operating room will be open only five days a week from 8:00-20:00. In such a scenario if a patient is admitted for a hip fracture on Friday afternoon it will be impossible to be compliant with the recommendation. This is how an organisational bottleneck could affect the clinical process. 54(a). What is the single most relevant outcome that can be influenced/determined by this part of the process of care? Please, indicate for each outcome its level of evidence (scientific literature and/or clinical expertise and/or your opinion).Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increased risk of negative outcomes (patients death and pressure sores). : Outcomes 54(b). What is the single most relevant outcome that can be influenced/determined by this part of the process of care? Please, indicate for each outcome its level of evidence (scientific literature and/or clinical expertise and/or your opinion).Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increased risk of negative outcomes (patients death and pressure sores). : Level of evidence 54(c). What is the single most relevant outcome that can be influenced/determined by this part of the process of care? Please, indicate for each outcome its level of evidence (scientific literature and/or clinical expertise and/or your opinion).Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increased risk of negative outcomes (patients death and pressure sores). : Reference/Citation 55(a). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Typology/category of patients should be excluded 46.According to your opinion, what is the most frequent setting where the above process is currently executed? (more than one answer allowed) 49.Could you please flag the not appropriate ones from the following list.

50.Please have a look at the below list of activities/interventions included in the subprocess (Occupational, Physical and
Respiratory assessment and management) that you examined before. Could you please provide us with your opinion ranking the importance of those activities from 1 to 13 where 1 is the most important? (we realize that some activities will get similar importance but to prioritize them, you cannot attribute the same ranking for several activities). Note: To rank the activities you can either attribute the number directly in the box or drag them in the order you wish. Q45 Q46 Q49 Q50 Q52 Q54 Q55 55(b). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Reasons 55(c). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Level of evidence 55(d). Could you please indicate the single most important typology/category of patients that should be excluded from this part of the process of MG care and the determining reason. Please include also the level of evidence of your answer (scientific literature and/or clinical expertise and/or your opinion). Example: After a hip fracture, clinical guidelines recommend immediate reparative surgery, within 24-48 hours from hospital admission. If the surgery is delayed, then there will be an increase in the risk of death and pressure sores. In this example, the patients with cardiac or renal failure, infections and uncontrolled diabetes or electrolyte abnormalities should be excluded, because they need to be visited cardiologists or nephrologists to evaluate the risk for surgery and often also require additional treatments and tests. This determines the impossibility to respect the appropriate timing of the operating room. Therefore, these patients can not be included in the pathway.: Reference/Citation